Provider Demographics
NPI:1114438017
Name:SOUTHLAKE VISION GROUP PLLC
Entity Type:Organization
Organization Name:SOUTHLAKE VISION GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:RONIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:682-554-2079
Mailing Address - Street 1:1104 GUADALUPE CT
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5885
Mailing Address - Country:US
Mailing Address - Phone:682-554-2079
Mailing Address - Fax:
Practice Address - Street 1:3004 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6618
Practice Address - Country:US
Practice Address - Phone:682-554-2079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty